20141076 Ver 1_Shoreline Stabilization_20141010

2 0 1 4 1 0 7 6
State of North Carolina
Department of Environment and Natural Resources
W__
Division of Water Resources
15A NCAC 02H .0500 — Water
Div6lon of Water R Quality Certification, Shoreline Stabilization
K &AI FORM: SSGP 10 -2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit rFOC:Fl f� 1650 Mail Service Center u Raleigh, NC 27699 -1650 0 2014
1. Applicant Information [15A NCAC 02H .0502(a)] Q-0 a e
1. Owner Information
Name: P, ; i iri XAI^ . t�
Mailing Address:
Telephone Number: )S� AP7K-Y1 9 2 Fax Number:
E -mail Address: ' e-/
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http: / /www.saw.usace.army. mil / Portals /59 /dots /regulatory/regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval: DWr�c�_r-
II. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining wails, docks, impervious surfaces,
FORM: SSGP 10 -2013 Page I of 4
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etc.), rip rap, excavation or dredging below Full'Pond/ Normal Water Level elevations,
,and construction access corridors. You may use the diagram provided at�the end of this
application form.
3' Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale
of some sort- a yard stick, shovel handle, etc.)
4. Location ,of the property (where work is to be conducted)
County: ji c- a.klll,h Nearest Town: ,0 u h vj
Subdivision name or site address (include phase /lot number): _ 1 ke /o-6�/q,
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Directions to site- please include road, names and numbers, landmarks, etc.:
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc:): 40M-e-, gU�G\ Si +*, ,
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: &C1 I e9
8. Describe�proposed work,(include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Vii,, r�@ o A Ci' ts� � nj a+ OLLQ,M- 1%'i )bI�-
Tut- i�aLSCr, �CC�1U11�1 -ts �is,�Fl����-.a `-ro Ii�1�STtA'�1� Ul C� 0- It
9. Will work be conducted from land? R__ From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls; etc.)
below the normal pool'lake level/ Normal Water Level in square feet or acres:
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11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap,.retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: 3-5� Q
12. Please describe the vegetation, above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance):
WAIr
r /Agent's Signature* [15A`NCAC 02H .0502'(f)l
/D -7
Date
'Agent's signature is valid only if an authorization letter from. the owner4s provided
FORM SSGP 10 -2013 Page 2 of 3

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Please approximately sketch the following infoi;mation on this,plan (provide dimensions for each
item, such as 10 ft 100 ft) *:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above,the Full Pond/ Normal Water Level elevation Main-c-
'3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation Non &
4. Location of any proposed structures such as buildings, retaining walls; docks; etc.
5. Location of °any excavation or dredging below,the Full, Pond/ Normal Water Level elevation VO
6. Location-of construction access corridors
FORM SSGP 10 -2013 Page 3 of 3

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Michael T Langley
NC License #31693
ULV- AeAb
3192 Lewis Road
'Elm CifY,,NC 27822
[phone]
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